Study Selection
Figure 1 presents the flow of the study selection. Two studies by Söderlund and Lindberg (Söderlund & Lindberg, 2001, 2007) and two studies by Wicksell et al. (Wicksell, Ahlqvist, Bring, Melin, & Olsson, 2008; Wicksell, Olsson, & Hayes, 2010) were from the same study project and, therefore, were treated as one, respectively. The risk of bias was assessed in eight studies (Andersen et al., 2020; Dunne, Kenardy, & Sterling, 2012; Ehrenborg & Archenholtz, 2010; Michaleff et al., 2014; Pato et al., 2010; Söderlund & Lindberg, 2001, 2007; M. J. Stewart et al., 2007; Wicksell et al., 2008; Wicksell et al., 2010). Table 1 demonstrates the results of the risk of bias assessment. One study (Andersen et al., 2020) did not have PEDro scores in the database, and the PEDro scores were determined by the two authors, where there was no disagreement. Six studies (Andersen et al., 2020; Dunne et al., 2012; Michaleff et al., 2014; Söderlund & Lindberg, 2001, 2007; M. J. Stewart et al., 2007; Wicksell et al., 2008; Wicksell et al., 2010) had a low risk of bias, and two studies (Ehrenborg & Archenholtz, 2010; Pato et al., 2010) had a high risk of bias.
Study Characteristics
The summary of the eight studies is presented in Table 2. Two studies have compared CBT with the wait-and-see control group (Dunne et al., 2012; Wicksell et al., 2008; Wicksell et al., 2010), where pain, disability, fear of physical activity, anxiety, depression, and posttraumatic stress in the short term were considered eligible for inclusion in the meta-analysis to investigate the effects of CBT alone. Two studies have compared CBT in addition to a comprehensive exercise program with advice alone (Michaleff et al., 2014; M. J. Stewart et al., 2007), where pain, disability, and QoL with SF-36’s physical and mental component summary scores in the long term were considered eligible for inclusion in the meta-analysis to investigate the combined effects of CBT and physical interventions.
Other studies were deemed ineligible for the meta-analysis due to the lack of multiple studies with similar interventions. Andersen et al. (Andersen et al., 2020) have compared trauma-focused CBT in addition to exercise with exercise only. Söderlund and Lindberg (Söderlund & Lindberg, 2001, 2007) have compared CBT in addition to physical therapy with physical therapy alone. Pato et al. (Pato et al., 2010) have compared CBT in addition to other treatments (physical therapy, infiltration, or medication) with other treatments alone. Ehrenborg and Archenholtz (Ehrenborg & Archenholtz, 2010) have compared CBT in addition to surface electromyography biofeedback training with CBT alone. In the eight studies, CBT was provided by psychologists in four studies (Andersen et al., 2020; Dunne et al., 2012; Pato et al., 2010; Wicksell et al., 2008; Wicksell et al., 2010) and by physical therapists in four studies (Ehrenborg & Archenholtz, 2010; Michaleff et al., 2014; Söderlund & Lindberg, 2001, 2007; M. J. Stewart et al., 2007). The corresponding authors were never contacted to resolve doubts about the types and treatment characteristics of CBT. Three studies (Andersen et al., 2020; Michaleff et al., 2014; M. J. Stewart et al., 2007) have evaluated the adverse events of CBT, where no serious adverse events were observed. Minor adverse events, including muscle soreness, stiffness, headaches, and/or exacerbation of existing symptoms, were reported in the CBT group (Table 2).
Meta-analysis
Only one study has reported changes in values from baseline to each follow-up point (Wicksell et al., 2010). In the other studies, no additional data were available, and the values at each follow-up point were used for the meta-analysis. No disagreement was found in any rating of the GRADE scores between the two authors.
CBT versus wait-and-see control
For short-term pain, 46 patients with chronic WADs from two studies (Dunne et al., 2012; Wicksell et al., 2008; Wicksell et al., 2010) were included in the meta-analysis, whose forest plot is presented in Figure 2. No statistically significant overall effect was observed (p = 0.11), indicating that CBT was not more effective than the wait-and-see control in reducing pain at the short-term follow-up. The I2 value was 0%, indicating insignificant heterogeneity. Due to a serious impression with two levels downgraded from the GRADE score, the quality evidence was considered low (Table 3).
For short-term disability, 46 patients with chronic WADs from two studies (Dunne et al., 2012; Wicksell et al., 2008; Wicksell et al., 2010) were included in the meta-analysis, whose plot is presented in Figure 3. CBT had a statistically significant overall effect (p = 0.05), indicating that CBT was more effective than the wait-and-see control in terms of disability reduction at the short-term follow-up. The I2 value was 0%, indicating insignificant heterogeneity. Due to a serious impression with two levels downgraded from the GRADE score, the quality evidence was considered low (Table 3).
For fear of physical activity in the short term, 46 patients with chronic WADs from two studies (Dunne et al., 2012; Wicksell et al., 2008; Wicksell et al., 2010) were included in the meta-analysis, whose forest plot is presented in Figure 4. CBT had a statistically significant overall effect (p = 0.001), indicating that CBT was more effective than the wait-and-see control in reducing the fear of physical activity at the short-term follow-up. The I2 value was 0%, indicating insignificant heterogeneity. Due to a serious impression with two levels downgraded from the GRADE score, the quality evidence was considered low (Table 3).
For short-term anxiety, 46 patients with chronic WADs from two studies (Dunne et al., 2012; Wicksell et al., 2008; Wicksell et al., 2010) were included in the meta-analysis, whose forest plot is presented in Figure 5. CBT had a statistically significant overall effect (p = 0.002), indicating that CBT was more effective than the wait-and-see control in reducing anxiety at the short-term follow-up. The I2 value was 0%, indicating insignificant heterogeneity. Due to a serious impression with two levels being downgraded from the GRADE score, the quality evidence was considered low (Table 3).
For short-term depression, 46 patients with chronic WADs from two studies (Dunne et al., 2012; Wicksell et al., 2008; Wicksell et al., 2010) were included in the meta-analysis, whose forest plot is presented in Figure 6. CBT had a statistically significant overall effect (p = 0.001), indicating that CBT was more effective than the wait-and-see control in reducing depression at the short-term follow-up. The I2 value was 0%, indicating insignificant heterogeneity. Due to a serious impression with two levels downgraded from the GRADE score, the quality evidence was deemed low (Table 3).
For posttraumatic stress in the short term, 46 patients with chronic WADs from two studies (Dunne et al., 2012; Wicksell et al., 2008; Wicksell et al., 2010) were included in the meta-analysis, whose forest plot is presented in Figure 7. CBT had no statistically significant overall effect (p = 0.34), indicating that CBT was not more effective than the wait-and-see control in reducing posttraumatic stress at the short-term follow-up. The I2 value was 0%, indicating insignificant heterogeneity. Due to a serious impression with two levels downgraded from the GRADE score, the quality evidence was deemed low (Table 3).
CBT in addition to physical interventions versus advice only
For long-term pain, 282 patients with chronic WADs from two studies (Michaleff et al., 2014; M. J. Stewart et al., 2007) were included in the meta-analysis, whose forest plot is presented in Figure 8. CBT in addition to physical interventions had no statistically significant overall effect (p = 0.09), indicating that CBT in addition to physical interventions was not more effective than advice in reducing pain at the long-term follow-up. The I2 value was 0%, indicating insignificant heterogeneity. Due to a serious impression with one level downgraded from the GRADE score, the quality evidence was deemed moderate (Table 3).
For long-term disability, 282 patients with chronic WADs from two studies (Michaleff et al., 2014; M. J. Stewart et al., 2007) were included in the meta-analysis, whose forest plot is presented in Figure 9. CBT in addition to physical interventions had a statistically significant overall effect (p = 0.01), indicating that CBT in addition to physical interventions was more effective than advice only in reducing disability at the long-term follow-up. The I2 value was 0%, indicating insignificant heterogeneity. Due to a serious impression with one level downgraded from the GRADE score, the quality evidence was considered moderate (Table 3).
For QoL in the long term, 282 patients with chronic WADs from two studies (Michaleff et al., 2014; M. J. Stewart et al., 2007) were included in the meta-analysis with the SF-36 scores. The forest plot of the physical component summary score in the SF-36 is presented in Figure 10, and that of the mental component summary score is presented in Figure 11. CBT in addition to physical interventions had no statistically significant overall effect (p = 0.09 for the physical component summary score; p = 0.32 for the mental component summary score), indicating that CBT in addition to physical interventions was not more effective than advice only in improving the QoL at the long-term follow-up. The I2 value was 0%, indicating insignificant heterogeneity. Due to a serious impression with one level downgraded from the GRADE score, the quality evidence was considered moderate (Table 3).